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Speaker Request Form
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* Indicates required question
Name (First Name/Last Name)
*
Your answer
Street Address
*
Your answer
City | State | Zip Code
*
Your answer
Phone number (include area code)
*
Your answer
Email
*
Your answer
Date of Event (mm,dd,year)
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Your answer
Time of Event (Example: 3 p.m.)
*
Your answer
Name of Event
*
Your answer
Expected Number of Attendees
Your answer
What kind of event?
*
Summit
Conference
Book Signing
Church Service (Prayer/Breakfast/Retreat, etc)
Other:
Required
What is your speaker/presenter budget?
*
Your answer
What kind of appearance would you like Dr. Yolanda Jerry to make?
Keynote Speaker
Presenter
Panelist
Host/Facilitate
Breakout Session
Other:
Are there any sensitive issues I should be aware of or topics I should avoid? (Yes/No) Include the sensitive issue in your response
Your answer
What are some of the current problems/challenges/breakthroughs experienced by your attendees, industry, organization, association or people? *
Your answer
What specific topics would you like for Dr. Yolanda Jerry to address?
*
Domestic Violence
Sexual Assault
Bullying
Empowerment
Other:
Required
Is Dr. Yolanda Jerry able to set up a table for products/information at this event?
*
Yes
No
Maybe
Any additional comments or information you would like for me to consider?
Your answer
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